Behavioral Health Services Inquiry Please fill out the form below. The information you provide will assist us in providing you with the best care. Legal Name * First Name Last Name Personal Name EDGE NJ is committed to affirming your personal name. We are required to capture your legal name for insurance purposes. Please understand that we know your personal name is the true reflection of who you are. First Name Last Name Sex * Female Male Intersex Female (MtF) Male (FtM) Non-Binary Pronouns * She, Her, Herself He, Him, Himself They, Them, Themselves Ze, Zir, Zirself Other Date of Birth * Please note: EDGE NJ provides care to individuals age 13 or older. MM DD YYYY Address * EDGE NJ primarily serves people living in Morris, Sussex, Warren, Union and Essex counties. However, if you are outside of these counties and in need of an affirming provider, please complete this form. Address 1 Address 2 City State/Province Zip/Postal Code Country County of Residence * Morris Sussex Warren Union Essex Email * Phone * (###) ### #### Best Mode of Contact * Phone Email Both Eligibility Demographics * EDGE NJ serves the LGBTQ+ Communities, people living with HIV, and those with an increased likelihood for contracting HIV. Any information you provide will assist us in determining which services you are eligible for. I identify as part of the LGBTQ+ Community. I am a parent/guardian of an LGBTQ+ child. I am a person living with HIV. I have an increased likelihood of contracting HIV (HIV+ Partner, Condomless Sex, IV Needle Use, etc.). I choose not to disclose at this time. Primary Insurance Coverage * Cost should never be a barrier to care. We accept most insurances. We also maintain various grants for underinsured and uninsured people. NJ Medicare NJ Medicaid Aetna Horizon NJ Family Care United Health Care Other Uninsured For which of the following reasons are you seeking Behavioral Health Counseling? * EDGE NJ provides outpatient counseling for up to 1 hour at weekly or bi-weekly intervals. If you are seeking more intensive services please call our office for a referral. We are committed to providing quality care for the following challenges. Adjustment Disorders/Coping with change Anxiety/Stress Depression Gender Affirming Letter of Support Gender Dysphoria Grief and Loss Mood Disorders (i.e. Bipolar Disorder) Neurodiversity (i.e. Autism, ADHD) Personality Disorders Substance Use Disorders/Recovery Trauma Other Please read and acknowledge the following: * EDGE NJ may take up to 5 business days to review online form submissions. We will contact you via your preferred method of communication as soon as possible. This form should not be used for immediate crisis needs. If you are having a mental health emergency, please call 911 or 988. Check here to indicate that you acknowledge and understand the above statement. Additional Info Please provide any additional information that may be relevant to your care. Thank you!We’ll get in touch with you shortly.
